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Pharmacy prior authorization guidelines

Our decision-making process

Some medications on our formulary need prior authorization before they can be dispensed. First, you’ll request prior authorization for a member’s medication. Then, we’ll review your request and make our decision using the Maryland Department of Health’s prior authorization guidelines as well as our own custom guidelines. 

 

Here are some of the guidelines we use in our decision making: 

 

Non-formulary and prior authorization guidelines (PDF)

 

Global Exception (PDF)

 

Actimmune (PDF)

 

Ambrisentan-Letairis (PDF)

 

Anthelmintics (PDF)

 

Austedo-Austedo XR (PDF)

 

Bosentan-Tracleer (PDF)

 

Botulinum toxins (PDF)

 

Brilinta (PDF)

 

Cablivi (PDF)

 

Calcipotriene (PDF)

 

Cayston (PDF)

 

Cequa and Cyclosporine Ophthalmic Emulsion (PDF)

 

CGRP Injectable IV Infusion (PDF)

 

CGRP Oral Nasal (PDF)

 

Cinqair (PDF)

 

Colony stimulating factors (PDF)

 

Compounded Drug Products (PDF)

 

Continuous Glucose Monitor (PDF)

 

Corlanor (PDF)

 

Cytokine and cell adhesion molecule antagonists (PDF)

 

Dalfampridine (PDF)

 

Dificid (PDF)

 

Endari (PDF)

 

Entresto (PDF)

 

Epoprostenol-Flolan-Veletri (PDF)

 

Eucrisa (PDF)

 

Exondys 51 (PDF)

 

Fasenra (PDF)

 

Fentanyl - Oral and Intranasal (PDF)

 

Griseofulvin (PDF)

 

Growth hormone (PDF)

 

HP Acthar (PDF)

 

Hereditary Angioedema (PDF)

 

Icosapent Ethyl (PDF)

 

Immune globulins (PDF)

 

Injectable osteoporosis (PDF) 

 

Jardiance (PDF)

 

Kalydeco (PDF)

 

Korlym (PDF)

 

Leqvio (PDF)    

 

Lidocaine Topical Patch (PDF)

 

Linezolid (PDF)

 

Linzess (PDF)

 

Lubiprostone (Amitiza) (PDF)

 

Lyrica (PDF)

 

Movantik (PDF)

 

Mulpleta (PDF)

 

Multaq (PDF)

 

Multiple sclerosis (PDF)

 

Nayzilam (PDF)

 

Nucala (PDF)

 

Omnipod (PDF)

 

One Touch Diabetic Test Strips (PDF)

 

Onychomycosis (PDF)

 

Opsumit (PDF)

 

Orenitram (PDF)

 

Orkambi (PDF)

 

Oxbryta (PDF)

 

Oxervate (PDF)

 

Ozempic and Trulicity (PDF)

 

Palforzia (PDF)

 

Penicillamine Trientine (PDF)

 

Promacta (PDF)

 

Proton Pump Inhibitor Post Limit (PDF)

 

Pyrimethamine (PDF)

 

Ranolazine Extended Release (PDF)

 

Recorlev (PDF)

 

Reyvow (PDF)

 

Riociguat-Adempas (PDF)

 

Rivastigmine Patch (PDF)

 

Roflumilast (PDF)

 

Sensipar (cinacalcet) (PDF)

 

Serostim (PDF)

 

Sildenafil-Revatio (PDF)

 

Skytrofa (PDF)

 

Spinraza (PDF)

 

Sucraid (PDF)

 

Symdeko (PDF)

 

Symlin (PDF)

 

Symproic (PDF)

 

Synagis (PDF)

 

Tadalafil Products (PDF)

 

Tavalisse (PDF)

 

Testosterone Agents (PDF)

 

Tetrabenazine (PDF)

 

Tezspire (PDF)

 

Tobramycin Inhalation (PDF)

 

Treprostinil-Remodulin (PDF)

 

Trikafta (PDF)

 

Tyrvaya (PDF)

 

Tyvaso (PDF)

 

Uptravi (PDF)

 

Ventavis (PDF)

 

Voriconazole (PDF)

 

Vyvgart (PDF)

 

Xifaxan 200mg (PDF)

 

Xifaxan 550mg (PDF)

 

Xiidra (PDF)

 

Xolair (PDF)

 

Zorbtive (PDF)

Hepatitis C guidelines

Hepatitis C therapy prior authorization form (PDF)

 

You can find more information on the Maryland Department of Health’s website, including their:

 

  • Hepatitis C clinical criteria  
  • Hepatitis C sample enhanced treatment plan  
  • Hepatitis C sample treatment plan  

For more information

If you have questions or would like a copy of these guidelines sent to you, call Provider Relations at 1-866-827-2710 (TTY: 711).  

Also of interest: